January 16, 2020European Heart Journal - Quality of Care and Clinical Outcomes52 citationsOpen Access
Validation of European Society of Cardiology pre-test probabilities for obstructive coronary artery disease in suspected stable angina
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Key Result
CTCA reduced 5-year coronary events compared to standard care, with the greatest difference in patients with a pre-test probability >15% (2.8% vs. 5.3%, P=0.01).
Study Design
Type
RCT (n=3,755)
Multicenter
Yes
Structured PICO
Does the 2019 ESC pre-test probability accurately predict obstructive coronary artery disease and help select patients for CTCA versus standard care?
P
Population
3,755 patients aged 30-75 years (46% women) with stable chest pain, followed for 5 years.
I
Intervention
Computed tomography coronary angiography (CTCA)
C
Comparator
Standard care
O
Outcome
Observed prevalence of obstructive coronary artery disease on CTCA and composite of 5-year coronary heart disease death or non-fatal myocardial infarctioncomposite
The 2019 ESC pre-test probability slightly underestimates obstructive CAD prevalence but effectively stratifies risk for future coronary events and identifies patients who may benefit most from CTCA.
Main Result
Absolute Event Rate: 2.8% vs 5.3%
p-value: p=0.01
Abstract
AIMS: To assess contemporary pre-test probability estimates for obstructive coronary artery disease in patients with stable chest pain. METHODS AND RESULTS: In this substudy of a multicentre randomized controlled trial, we compared 2019 European Society of Cardiology (ESC)-endorsed pre-test probabilities with observed prevalence of obstructive coronary artery disease on computed tomography coronary angiography (CTCA). We assessed associations between pre-test probability, 5-year coronary heart disease death or non-fatal myocardial infarction and study intervention (standard care vs. CTCA). The study population consisted of 3755 patients (30-75 years, 46% women) with a median pre-test probability of 11% of whom 1622 (43%) had a pre-test probability of >15%. In those who underwent CTCA (n = 1613), the prevalence of obstructive disease was 22%. When divided into deciles of pre-test probability, the observed disease prevalence was similar but higher than the corresponding median pre-test probability median difference 2.3 (1.3-5.6)%. There were more clinical events in patients with a pre-test probability >15% compared to those at 5-15% and 15% (2.8% vs. 5.3%, log rank P = 0.01), although this interaction was not statistically significant on multivariable modelling. CONCLUSION: The updated 2019 ESC guideline pre-test probability recommendations tended to slightly underestimate disease prevalence in our cohort. Pre-test probability is a powerful predictor of future coronary events and helps select those who may derive the greatest absolute benefit from CTCA.